Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute and chronic respiratory failure with hypoxia, COPD, and pneumonia did not receive oxygen therapy as ordered by the physician. The resident, who had moderate cognitive impairment, was admitted with a physician order for oxygen at two liters per minute via nasal cannula every shift for shortness of breath. However, during an observation, the resident was found to be receiving only one liter of oxygen per minute instead of the prescribed two liters. The Director of Staff Development/Infection Preventionist confirmed that the resident was receiving less oxygen than ordered and acknowledged that physician orders should be followed. The Director of Nursing also stated that oxygen is considered a medication and must be administered according to physician orders. Review of the facility's policy indicated that medications are to be administered as prescribed and in accordance with good nursing practices. This failure to follow the physician's order for oxygen administration constituted a breach of professional standards of quality.